Centre for Reproductive Immunology and Pregnancy Pre-Appointment History Sheet

Transcription

1 Please fill in the below table with your details: Title First Name Surname Date of Birth and age Occupation Do you smoke? (please circle) If yes, how many per day?. ne Low Moderate High How is your alcohol intake (please circle) Are you on any regular medications? Do you have any allergies? Allergies: Please fill in the below table with your partner s details: Title First Name Surname Date of Birth Occupation Do you smoke? (please circle) If yes, how many per day?. ne Low Moderate High How is your alcohol intake (please circle) Are you on any regular medications? Do you have any allergies? Allergies: How long have you been with your partner?.

2 ren (Sex, Age, Name, Weight and delivery mode) s /Pregnancy of unknown location Stimulated Cycles & medication used Stillbirths Please fill in the below table with the number you have had for all those applicable: Please fill in the below table for each you have had in the order from your first to the latest: (If you have had more than 5 then please, continue on the back of the sheet) Pregnancy Outcome Year Type of conception Gestation miscarriage diagnosed at Type of i.e complete/misse d Gestation miscarriage size Management of Please fill in table below for any IVF attempts you may have had:

3 Type of IVF Where IVF done Year Number of eggs collected Number of fertilised embryos Number of embryos or blastocysts transferred Outcome Please fill in table below with your gynaecological history: Cycle length Number of days of bleeding Blood Loss Last Menstrual Period (Please leave blank for Mr Shehata to fill in) Do you get any bleeding between periods? Do you get any bleeding after intercourse? Do you get any pain during intercourse? Have you had any of the following investigations if so in what year: Light Average Heavy Hysteroscopy Laparoscopy HyFosy HSG

4 Have you had pelvic surgery for any of the following and if so in what year: Are you up to date with your cervical smears? Have you ever had an abnormal smear? Fibroids Ovarian Cysts If yes in which year If yes how was it treated?.. Please fill in table below with your medical history: Do you have any medical history of: Diabetes : Type I Type II Hypertension Glaucoma Thyroid Asthma Blood Clots Other medical issues

5 Do you take any multivitamins while you are trying? If please provide the name of them below: Please fill in table below with your family history: Do you have any family history of: Diabetes and if yes who and which type? Type I. Type II. Hypertension and if yes who? -. Glaucoma and if yes who? -. Thyroid and if yes who? -. Recurrent miscarriages and if yes who? -. Other family history Please fill out the below table with your full address and contact details: Full address:

6 Contact number: Partner s number: address: Please fill out the below table with your GP details GP Surgery GP name GP surgery address GP telephone number GP fax number Would you like all correspondence to be copied to your GP To be completed by Mr Shehata at your appointment: Investigations/Results Date: Thrombophilia rmal Abnormal Type of abnormality: Pre-Pregnancy rmal High

7 NK CD 16/56 Count NK CD 16/56% Pre-Pregnancy rmal Borderline High Very High NK CD69 NK Cytotoxicity rmal High Best Suppression IVIG Best Suppression Prednisolone Best Suppression Intralipid TNFα rmal Abnormal TB Test Negative Equivocal Positive Thyroid Antibodies rmal Weak Positive Strong Positive TPO TGA ANA rmal Weak Positive Strong Positive Gliadin Antibodies rmal Weak Positive Strong Positive IgG/IgA TFT rmal High TSH only Abnormal Prolactin rmal Abnormal Ovarian Reserve FSH LH E2 AMH FBC rmal Abnormal U&E s rmal Abnormal LFT s rmal Abnormal Clotting Profile 1 rmal Abnormal Karyotyping rmal Abnormal Female Male Blood Group + Rhesus Factor Scan Summary rmal PCO Anatomical Abnormality Vaginal Swabs rmal Abnormal Type of Abnormality: IB Gen Semen Analysis rmal Abnormal Type of Abnormality: DNA Fragmentation Transvaginal Scan details: Uterus: rmal Abnormal Type of Abnormality: Position Size: Fibroids: Anterverted Retroverted Axial Details Right Ovary:

8 Size: Appearance: Antral Follicle Count Left Ovary: Size: Appearance: Antral Follicle Count: Date: Day of Cycle: Follow up plan Date: 1. Humira: : x 2 or x 4 2. Treatment Programme: rmal Borderline High Complex Very High 3. Hydroxychloroquine 4. action Aspirin: 75mg 150mg Prednisolone (mg): 25mg or 40mg Folic acid (mg): 0.4 or 5mg Omeprazole (mg): 20mg od Metformin (mg): 500 or 1000 od /bd / tds / qds Thyroxine (mcg): Dose: Cyclogest 400mg od/ bd Hydroxychloroquine (mg): 400 LMWH: OD or BD Fragmin 5000iu Clexane 40mg Info Sheets given or Intralipid Infusion 4 or 5 times Side Effects explained or IVIG Consent given or Others Patient made aware that the drugs are not licenced for use in and we lack scientific evidence to show that the treatment works or